The importance of community during rapid development: The influence of social networks on acute gastrointestinal illness in rural Ecuador.

Social networks are often measured as conduits of infection. Our prior cross-sectional analyses found that denser social ties among individuals reduces transmission of acute gastrointestinal illness (AGI) in coastal Ecuador; social networks can describe both risk and protection. We extend findings to examine how social connectedness influences AGI longitudinally in Ecuador from 2007 to 2013, a time of rapid development, using a two-stage Bayesian hierarchical model to estimate multiple network effects. A larger community network of people to discuss important matters with was consistently protective against AGI over time, and a network defined by people passing time together became a stronger measure of risk, due to increasing population density and travel. These networks were interdependent: the joint effect of having a small passing time network and large important matters network reduced the odds of AGI over time (2007: OR 1.16 (95% CI: 0.94, 1.44), 2013: OR 0.56 (95% CI: 0.45, 0.71)); and synergistic: the people an individual passed time with became the people they discussed important matters with. Focus groups emphasized that with greater remoteness came greater community cohesion resulting in safer WASH practices. Social networks can enhance and reduce health differently as social infrastructure evolves, highlighting the importance of community-level factors in a period of rapid development.

"Chicken dumping": Motivations and perceptions in shifting poultry production practices.

Non-governmental organizations (NGOs) often implement overseas development aid through intensive small-scale animal agriculture to alleviate food insecurity in low- and middle-income countries. Intensive animal farming can pose unclear outcomes to households engaged in the practice because of the reliance on industrial animal breeds that are reared with antibiotics and raised in higher densities compared to traditional scavenging husbandry systems. As a result, intensive small-scale farming operations that lack proper infrastructure, training, and financial resources could facilitate the spread of antimicrobial resistance and infectious diseases. We applied a mixed-methods framework towards analyzing the effectiveness of small-scale broiler chicken farming in northern Ecuador. First, from May 2016 - May 2017, our observational surveys indicated that intensive small-scale poultry farming follows a boom-and-bust cycle that is extremely vulnerable to environmental stressors. Second, in May 2016, we followed a cohort of households enrolled in a poultry development project led by an NGO. We observed a substantial decline in chicken survivorship from Survey period 1 to 2 (mean chicken count decrease from 50 to 35 corresponding to a 70% survivorship) and from Survey period 2 to 3 (mean chicken count decrease from 35 to 20.3 corresponding to a 58% survivorship). Heads of households were self-reporting broiler chicken survivorship substantially higher than our recorded observations during survey period two (46 compared to 35 respectively) and three (44.3 compared to 20.3 respectively). We speculate that if households continue to inaccurately report poultry demographics, then it could perpetuate a negative feedback loop where NGOs continue to conduct the same intervention practices without receiving accurate outcome metrics. Third, we used semi-structured questionnaires to determine that access to financial resources was the major motivation for determining when to farm broiler chickens. Intensive small-scale poultry farming can be unreliable and disease-enhancing, yet also associated with dubious self-reports of success.

Mass Gatherings and Diarrheal Disease Transmission Among Rural Communities in Coastal Ecuador.

Mass gatherings exacerbate infectious disease risks by creating crowded, high-contact conditions and straining the capacity of local infrastructure. While mass gatherings have been extensively studied in the context of epidemic disease transmission, the role of gatherings in incidence of high-burden, endemic infections has not been previously studied. Here, we examine diarrheal incidence among 17 communities in Esmeraldas, Ecuador, in relation to recurrent gatherings characterized using ethnographic data collected during and after the epidemiologic surveillance period (2004-2007). Using distributed-lag generalized estimating equations, adjusted for seasonality, trend, and heavy rainfall events, we found significant increases in diarrhea risk in host villages, peaking 2 weeks after an event's conclusion (incidence rate ratio, 1.21; confidence interval, adjusted for false coverage rate of ≤0.05: 1.02, 1.43). Stratified analysis revealed heightened risks associated with events where crowding and travel were most likely (2-week-lag incidence rate ratio, 1.51; confidence interval, adjusted for false coverage rate of ≤0.05: 1.09, 2.10). Our findings suggest that community-scale mass gatherings might play an important role in endemic diarrheal disease transmission and could be an important focus for interventions to improve community health in low-resource settings.

Writing Assignments in Epidemiology Courses: How Many and How Good?

OBJECTIVES: Schools and programs of public health are concerned about poor student writing. We determined the proportion of epidemiology courses that required writing assignments and the presence of 6 characteristics of these assignments. METHODS: We requested syllabi, writing assignments, and grading criteria from instructors of graduate and undergraduate epidemiology courses taught during 2016 or 2017. We assessed the extent to which these assignments incorporated 6 characteristics of effective writing assignments: (1) a description of the purpose of the writing or learning goals of the assignment, (2) a document type (eg, article, grant) used in public health, (3) an identified target audience, (4) incorporation of tasks that support the writing process (eg, revision), (5) a topic related to a public health problem that requires critical thinking (1-5 scale, 5 = most authentic), and (6) clear assignment expectations (1-5 scale, 5 = clearest). RESULTS: We contacted 594 instructors from 58 institutions and received at least some evaluable materials from 59 courses at 28 institutions. Of these, 47 of 53 (89%) courses required some writing. The purpose was adequately described in 11 of 36 assignments, the required document type was appropriate in 19 of 43 assignments, an audience was identified in 6 of 37 assignments, and tasks that supported a writing process were incorporated in 19 of 40 assignments. Median (interquartile range) scores were 5 (1-5) for an authentic problem that required critical thinking and 4 (2-5) for clarity of expectations. CONCLUSIONS: The characteristics of writing assignments in public health programs do not reflect best practices in writing instruction and should be improved.

Social cohesion and passive adaptation in relation to climate change and disease.

Climate change affects biophysical processes related to the transmission of many infectious diseases, with potentially adverse consequences for the health of communities. While our knowledge of biophysical associations between meteorological factors and disease is steadily improving, our understanding of the social processes that shape adaptation to environmental perturbations lags behind. Using computational modeling methods, we explore the ways in which social cohesion can affect adaptation of disease prevention strategies when communities are exposed to different environmental scenarios that influence transmission pathways for diseases such as diarrhea. We developed an agent-based model in which household agents can choose between two behavioral strategies that offer different levels of protection against environmentally mediated disease transmission. One behavioral strategy is initially set as more protective, leading households to adopt it widely, but its efficacy is sensitive to variable weather conditions and stressors such as floods or droughts that modify the disease transmission system. The efficacy of the second strategy is initially moderate relative to the first and is insensitive to environmental changes. We examined how social cohesion (defined as average number of household social network connections) influences health outcomes when households attempt to identify an optimal strategy by copying the behaviors of socially connected neighbors who seem to have adapted successfully in the past. Our simulation experiments suggest that high-cohesion communities are able to rapidly disseminate the initially optimal behavioral strategy compared to low-cohesion communities. This rapid and pervasive change, however, decreases behavioral diversity; i.e., once a high cohesion community settles on a strategy, most or all households adopt that behavior. Following environmental changes that reduce the efficacy of the initially optimal strategy, rendering it suboptimal relative to the alternative strategy, high-cohesion communities can fail to adapt. As a result, despite faring better early in the course of computational experiments, high-cohesion communities may ultimately experience worse outcomes. In the face of uncertainty in predicting future environmental stressors due to climate change, strategies to improve effective adaptation to optimal disease prevention strategies should balance between intervention efforts that promote protective behaviors based on current scientific understanding and the need to guard against the crystallization of inflexible norms. Developing generalizable models allows us to integrate a wide range of theories multiple datasets pertaining to the relationship between social mechanisms and adaptation, which can provide further understanding of future climate change impacts. Models such as the one we present can generate hypotheses about the mechanisms that underlie the dynamics of adaptation events and suggest specific points of measurement to assess the impact of these mechanisms. They can be incorporated as modules within predictive simulations for specific socio-ecological contexts.

Where science meets policy: comparing longitudinal and cross-sectional designs to address diarrhoeal disease burden in the developing world.

BACKGROUND: Longitudinal studies are considered preferable to cross-sectional studies for informing public health policy. However, when resources are limited, the trade-off between an accurate cross-section of the population and an understanding of the temporal variation should be optimized. When risk factors vary more across space at a fixed moment in time than at a fixed location across time, cross-sectional studies will tend to give more precise estimates of risk factor effects and thus may be a better source of data for policy judgments. METHODS: We conducted a diarrhoeal disease surveillance of 5616 individuals within 19 Ecuadorian villages. This data set was used to mimic cross-sectional and longitudinal studies by restricting focus to a single week and a single village, respectively. We compared the variability in risk factor effect estimates produced from each type of study. RESULTS: For household risk factors, the effect estimates produced by the longitudinal studies were more variable than their cross-sectional counterparts, which can be explained by greater spatial than temporal variability in the risk factor distribution. For example, the effect estimate of improved sanitation was almost twice as variable in longitudinal studies. CONCLUSIONS: In our study, cross-sectional designs yielded more consistent evaluations of diarrhoea disease risk factors when those factors varied more between villages than over time. Cross-sectional studies can provide information that is representative across large geographic regions and therefore can provide insight for local, regional and national policy decisions. The value of the cross-sectional study should be reconsidered in the public health community.

[Diarrheal illnesses on the Ecuadorian coast: socio-environmental changes and health concepts]. / Males diarreicos en la costa ecuatoriana: cambios socioambientales y concepciones de salud.

The authors present an ethnoepidemiological study of diarrheal illnesses in 21 communities on the northern coast of Ecuador, where numerous social and environmental changes have taken place since 2001 due to a new highway. As communities realize that nature itself is changing, changes occur in their interpretations of health and disease, which the authors present through a taxonomic classification of diarrheal illnesses. Given the high incidence of diarrheal diseases, alternative concepts have emerged (as compared to those of biomedicine) in relation to causes, symptoms, and treatments. The non-biomedical and biomedical systems overlap, with mixtures of coexistence and resistance. Recognizing this reality means understanding a series of challenges for the official health system, including the indiscriminate use of antibiotics, non-use of health services for some diseases, and perceived relations between environmental contamination and the efficacy of modern and traditional medicines.

Males diarreicos en la costa ecuatoriana: cambios socioambientales y concepciones de salud / Diarrheal illnesses on the Ecuadorian coast: socio-environmental changes and health concepts

Presentamos una etnoepidemiologia de las enfermedades diarreicas en 21 pueblos de la costa norte del Ecuador, zona en la cual hay muchos cambios sociales y ambientales desde 2001 por la presencia de una nueva carretera. Con percepciones de que la misma naturaleza esta cambiando, vienen cambios en interpretaciones de lo que es salud y enfermedad, que presentamos en forma de una taxonomia de males diarreicos. Ante la fuerte incidencia de las enfermedades diarreicas, existen concepciones alternativas a la biomedicina en cuanto a sus causas, sintomas y tratamientos. Hay superposiciones entre sistemas no-biomedicas y biomedicos, en donde hay mezclas de coexistencia y resistencia. Reconocer esto es entender una serie de desafios para el sistema de salud oficial, incluyendo el uso indiscriminado de antibioticos, el no uso de servicios de salud para algunos males, y relaciones percibidas entre contaminacion ambiental y la eficacia de las medicinas moderna y tradicional.

The authors present an ethnoepidemiological study of diarrheal illnesses in 21 communities on the northern coast of Ecuador, where numerous social and environmental changes have taken place since 2001 due to a new highway. As communities realize that nature itself is changing, changes occur in their interpretations of health and disease, which the authors present through a taxonomic classification of diarrheal illnesses. Given the high incidence of diarrheal diseases, alternative concepts have emerged (as compared to those of biomedicine) in relation to causes, symptoms, and treatments. The non-biomedical and biomedical systems overlap, with mixtures of coexistence and resistance. Recognizing this reality means understanding a series of challenges for the official health system, including the indiscriminate use of antibiotics, non-use of health services for some diseases, and perceived relations between environmental contamination and the efficacy of modern and traditional medicines.

Raising the level of analysis of food-borne outbreaks: food-sharing networks in rural coastal Ecuador.

OBJECTIVES: Consuming contaminated food is a well-documented individual-level risk factor for diarrheal disease. The sharing of food also influences the distribution of diarrheal disease risk through a community and region. Understanding this social process at a population level is therefore an important dimension of risk not captured by standard individual-level analyses. We examined social networks related to food-sharing in rural villages at 2 scales: within a village, examining whether connections within these networks clustered or were uniformly spread; and among villages, looking at whether food-sharing networks differed according to the village's remoteness from a population center. METHODS: We surveyed 2129 individuals aged 13 years and older in 2003-2004, within a representative (block-randomized) sample of 21 rural villages in Esmeraldas province, northern coastal Ecuador. We calculated degree (number of social contacts) for a social network defined by sharing food. RESULTS: Networks of households sharing food differ according to remoteness from a metropolitan center. On average, residents living in "far villages" had 2 more social contacts than those in "close villages," and 12 more years of residence in their village. Estimates of transmissibility (a measure of outbreak potential) based on network structure varied as much as 2-fold across these villages. CONCLUSIONS: Food-sharing practices link particular households in rural villages and have implications for the spread of food-borne pathogens. The food-sharing networks in remote rural villages are heterogeneous and clustered, consistent with contemporary theories about disease transmitters. Network-based measures may offer tools for predicting patterns of disease outbreaks, as well as guidance for interventions.